« Prévention primaire des psychopathologies » : appellation contrôlée

La prévention psychosociale est souvent une notion galvaudée et abordée avec une familiarité trompeuse. Plusieurs facteurs peuvent expliquer en partie ce mauvais usage : réactions confuses au modèle médical, association inopportune des termes "préventif" et "communautaire", distinction plus ou moins claire entre trois niveaux de prévention, malentendu autour du concept de facteur de risque et définition trop générale du concept de promotion. Une des spécificités du fait psychopathologique est qu'il se prête mal à une dichotomie "avant /après" l'apparition des symptômes. C'est pourquoi le champ préventif devrait identifier ses cibles en fonction de facteurs étiologiques plutôt que symptomatologiques. Ainsi, pour nous, la véritable prévention ne devrait comprendre que des interventions proactives destinées, soit à la neutralisation d'influences pathogènes, soit à la promotion de compétences susceptibles de rendre la population plus robuste.Psychosocial prevention is often, and mistakenly, disparaged or approached with unwarranted familiarity. A number of factors could provide a partial explanation for this mistake: confused rea-tions to the medical model, an unfortunate association of the terms "preventive" and "community," lack of distinction between three levels of prevention, misunderstandings around the concept of risk factor, and an overly general definition of the concept of promotion. One specific fact about psychopathology is that it does not fit well into the dichotomous "before / after" appearance of symptoms. This is why the preventive field must identify its targets in terms of etiological rather than symptomological factors. Thus, for us, true prevention must include only proactive interventions meant either for neutralization of pathological influences, or for promotion of areas that are aimed at making the population healthier

L’après-suicide, une expérience unique de deuil?

Le groupe d'étude national sur le suicide au Canada suggère que les personnes qui vivent un deuil suite à un suicide forment un groupe à risque suicidaire. La littérature rapporte que ces endeuillés ont un taux de suicide neuf fois plus élevé que la population générale. Des auteurs suggèrent que ce type de deuil est plus intense et plus long que d'autres formes de deuil, constat que d'autres ont remis en doute. Qu'en est-il? Le deuil suite à un suicide est-il différent? S'agit-il d'une expérience unique de deuil? Un examen attentif de l'ensemble des études nous apprend que le deuil suite à un suicide présente des caractéristiques particulières, qui se manifestent davantage chez des personnes plus vulnérables.Canada's national task force on suicide suggests that people who mourn a suicide make up a group that is itself at risk. Literature shows that mourners of a suicide have a suicide rate that is nine times higher than average. While some authors suggest that this type of mourning is more intense and of a longer duration that for other types of mourning, other authors doubt this hypothesis. But what happens in reality ? Is suicide mourning truly different from other types of mourning? Is it really a unique mourning experience? These are some of the questions the authors of this article have attempted to answer. Following an in-depth review of studies on the matter, the authors conclude that the mourning of a suicide encompasses certain characteristics that manifest themselves especially in more vulnerable people

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Biological heterogeneity in idiopathic pulmonary arterial hypertension identified through unsupervised transcriptomic profiling of whole blood

Idiopathic pulmonary arterial hypertension (IPAH) is a rare but fatal disease diagnosed by right heart catheterisation and the exclusion of other forms of pulmonary arterial hypertension, producing a heterogeneous population with varied treatment response. Here we show unsupervised machine learning identification of three major patient subgroups that account for 92% of the cohort, each with unique whole blood transcriptomic and clinical feature signatures. These subgroups are associated with poor, moderate, and good prognosis. The poor prognosis subgroup is associated with upregulation of the ALAS2 and downregulation of several immunoglobulin genes, while the good prognosis subgroup is defined by upregulation of the bone morphogenetic protein signalling regulator NOG, and the C/C variant of HLA-DPA1/DPB1 (independently associated with survival). These findings independently validated provide evidence for the existence of 3 major subgroups (endophenotypes) within the IPAH classification, could improve risk stratification and provide molecular insights into the pathogenesis of IPAH

A Programme of College Education for Mothers with Small Children: An Evaluation of its Effects on Mental Health

An innovative programme in education and mental health for mothers (largely middle class) of pre-school children has been established by Marianopolis College in Montreal, in collaboration with the Mental Hygiene Institute. Many young mothers feel alienated from a rapidly changing society and would like to return to their studies but the difficulties inherent in such a step prevent most from doing so. Aware of these feelings of stress, frustration, and alienation, the College established a programme whereby the women could attend classes during the morning hours and bring their children with them to the free nursery school on campus, which was organized specifically for this purpose. Some courses were offered to the women as a group, thus lessening the tension of attending classes alone with much younger students.Evaluation of the first year of the project revealed that these women were capable of integrating their roles of wife, mother, and student; had achieved a sense of competence enabling them to pursue further studies individually; and for the most part, were now able to choose an occupational goal. In future it is intended to extend the programme so that mothers of lower socio-economic levels could avail themselves of this same opportunity

Les échelles de mesure de l’anxiété face à la mort : L’amorce d’une analyse

Les échelles de mesure de l’anxiété face à la mort ont connu un grand essor au cours des dernières années. Leur développement est attribuable au désir de mieux comprendre et connaître le phénomène. Toutefois, les chercheurs sont constamment confrontés à un problème de définition de ce concept qui réfère à une expérience subjective mettant en cause des composantes cognitives et affectives.Jusqu’à maintenant, la majorité des échelles sont construites sans référence explicite à une base théorique. L’application de ces instruments présente un intérêt, principalement dans le domaine de la recherche, et se montre limitée quant à son utilisation clinique.In recent years, there has been an increase in the development of death anxiety scales. The aim was to enlarge and deepen our understanding of this phenomenon. Researchers, however, have been constantly confronted with the inability to define the concept of death anxiety which is essentially a subjective experience with both cognitive and affective components. Furthermore these scales have been based on atheoritical constructs. The application of these scales is primarily for research purposes and have limited clinical application